Prognostic value of clinical markers of reperfusion in patients with acute myocardial infarction treated by thrombolytic therapy.

Patients who cannot be reperfused after thrombolytic therapy have a high mortality rate. Noninvasive clinical markers of reperfusion have been widely studied, yet their prognostic significance remains unclear. To assess the prognostic value of commonly used noninvasive clinical markers of early reperfusion we studied 327 patients who received intravenous thrombolytic treatment (1.5 MU streptokinase in 1 hour or 100 mg alteplase in 3 hours) within 6 hours of acute infarction. Successful clinical reperfusion (SCR) was defined as the presence of at least two of the following criteria at 2 hours after thrombolytic treatment: (1) significant relief of pain (a 5-point reduction on a 1 to 10 subjective scale), (2) > or =50% reduction of sum of ST segment elevation, and (3) abrupt initial increase of creatine kinase levels (more than twofold over the upper-normal or baseline elevated values). Clinical variables that were significantly associated by univariate analysis were tested by multivariate analysis to obtain independent predictors of 30-day mortality rate. SCR was present in 210 (64%) patients (group 1), and absent in 117 (36%) patients (group 2). The groups were similar for most baseline characteristics, although group 2 patients were slightly older (mean 60 vs 57 years, p < 0.02). Thirty-day outcomes for group 2 patients compared with group 1 patients were heart failure in 23.1% and 10.5% (p < 0.005), progression to cardiogenic shock in 12.8% and 0.5%, (p < 0.00001), and death in 16.2% and 3.8% (p < 0.0001), respectively. By multivariate analysis the Killip class at admission (p < 0.00001), the absence of SCR (p = 0.017), anterior infarct location (p = 0.021), and age (p = 0.03) were independent predictors of mortality rate, and sex (p = 0.051) had borderline significance. The absence of SCR defined a group of patients with significantly higher mortality rate (odds ratio 4.89, 95% confidence interval 2.07 to 11.57). Three simple noninvasive clinical criteria of successful reperfusion may be used to identify a group of patients with poor prognosis after thrombolytic therapy in whom alternative strategies could be applied.

[HELLP syndrome in the "Daniel A Carrion" National Hospital: report of cases]. / Síndrome HELLP en el Hospital Nacional "Daniel A. Carrión": reporte de 2 casos.

HELLP syndrome is an unusual complication of severe preeclampsia- eclampsia and is characterized by hemolysis (microangiopathic), elevated liver enzymes and thrombocytopenia. It is present in 2 to 19.3% of patients with toxemia and in 0.85% of all pregnancies. We present 2 cases of Hellp syndrome post-partum (in less than 31% of patients, according to literature) that fulfill with University of Tennessee diagnostic criteria, with clinical and laboratory features as described by literature. The second case presented as a complication, disseminated intravascular coagulation (DIC), which complicates Hellp syndrome in about 38% of patients. We review the clinical, epidemiologic and laboratory features, as well as, differential diagnosis, complications and management of Hellp syndrome.

[Peptic ulcer in patients with cirrhosis]. / Enfermedad ulcerosa péptica en pacientes cirróticos.

This study was carried out at the of gastroenterology service from Hospital Nacional "Daniel A. Carrión" Callao-Peru, between June 1993 and May 1994, in order to determine the incidence, as well as, the clinical and endoscopic features of peptic ulcer disease in cirrhotic patients. 24 out of 46 (52.17%) hospitalized cirrhotic patient during this period, had peptic ulcer disease. The male:female ratio was 1:1. The mean age was 63.54 years, ranging from 44 to 90. There was statistical association (p < 0.05) between the severity of liver disease determined by Child Pugh Score and the presence of gastric ulcer. Regarding symptomatology, 54.16% had hematemesis and/or melena and 37.5% were asymptomatic. 6 patients had 2 or more ulcers, presenting the total series as a whole 35 ulcers, whose size ranged from 0.4 a 1.2 cm. Gastric antrum was the most often location (60%) followed by duodenal bulb (20%). We conclude that peptic ulcer disease in our cirrhotic patients is more frequent than reported by international literature (5-32%). Severity of liver disease was associated to gastric ulcer.

[Polypoid lesions of the gallbladder]. / Lesiones polipoideas de la vesícula biliar.

This retrospective analysis evaluated 25 patients with benign polypoid lesions and 2 cases with malignant polyps of the gallbladder who had undergone cholecystectomy at Belén Hospital, Trujillo, Perú, from January, 1966 through December, 1993 in a attempt to elucidate the clinicopathological aspects of these patients. Cholelithiasis and cholesterolosis were present as associated findings in about 68% and 12% of patients respectively. The median age was of 48.8 +/- 15 years, the male:female ratio was 1:4, a right upper quadrant pain was the most common symptom (100%) and nonvisualization of a diseased gallbladder was seen in about 44% of cholecystograms. Microscopically, the lesions were classified as follow: Hyperplasias (n = 11), adenomas (n = 10), cholesterol polyps (n = 2), inflammatory polyps (n = 2) and malignant polyps (n = 2). Seventy six percent of benign lesions measured less than 0.5 cm and 12% were multiple lesions. The average diameter of malignant polyps was larger than 3 cm. We concluded that the benign epithelial tumors of the gallbladder are extremely rare cases and the treatment of choice for adenomatous polyps should be surgical for the possibility of developing malignant transformation.

[An index of the severity of intestinal gangrene due to colonic volvulus]. / Puntaje de severidad de la gangrena intestinal por vólvulo de colon.

This retrospective analysis evaluated 50 patients with gangrenous colonic volvulus two cases with ileocecal volvulus, one case with volvulus of the colon transverse and 47 cases with sigmoid volvulus- who were managed by primary resection with anastomosis (n = 21) or resection plus colostomy (n = 29) at Belén Hospital, Trujillo, Perú, from January 1, 1967 to July 31, 1993. The principal aim of the study was to identify by univariate analysis the combination of predictive risk factors for postoperative mortality. The following factors were associated with increased mortality: mean arterial pressure lower than 70 mmHg (p = 0.004), presence of purulent or fecaloid peritoneal fluid (p = 0.013) or evidence of macroscopic bowel perforation (p < 0.001). A method of quantifying the risk of mortality following gangrene of the loop using these factors was described. Each factor was given a weight value ranging from 0 a 2 (0 = major, 1 = moderate, 2 = minor) according to the severity of injury estimate. The sum of the individual factor scores comprised the final score of the Severity of Gangrenous Colon by Volvulus (S.S.G.C.). In this series the 30-day mortality rate was of 30%. A S.S.G.C. resulted greater than 4 in 34 (68%) of the patients. This was associated with a 9% mortality rate and contrasted to a 75% when the S.S.G.C. was equal to or less than 4. Mortality developed in 33% of the patients operated on using an immediate anastomosis (S.S.G.C., 4.2 +/- 0.99) and it was of 28% in those whose operation was resection plus colostomy (S.S.G.C., 3 +/- 0.87).(ABSTRACT TRUNCATED AT 250 WORDS)

[Surgical mortality and long-term recurrence of ileocecal volvulus]. / Mortalidad operatoria y recurrencia a largo plazo por vólvulo ileocecal.

Acute ileocecal volvulus is a condition of the abdomen which requires emergency treatment and is currently managed by several methods with a mortality rate of 25%. Surgical options include detorsion, cecostomy for nongangrenous volvulus or resection when gangrene is present. We studied the mortality and recurrence rate of ileocecal volvulus. This retrospective analysis evaluated 16 patients who underwent operation at Belen Hospital, Trujillo, Peru, between January 1966 and August 1992. As of August 1992, median follow-up was 160 months for 13 surviving patients (range, 6 to 307 months). Eleven men and 5 women with a median age of 52.3 + 21.1 years (range, 9 months to 83 years) formed the study population. Sixty eight percent of cases were 41 to 80 years of age and all women were than 40 years of age. Most of them were from the Peruvian Andes (81.3%), were from Indian and Spanish extraction (93.7%), and farmers (50%). Twelve patients (75%) developed a chronic ileocecal volvulus and 4 (25%) had an acute presentation. The clinical picture presented as large bowel obstruction in all patients. An ileocecal volvulus was accurately diagnosed by plain films of the abdomen in only 2 patients (16%) pre-operatively. A variety of procedures were used: cecopexy (9 cases), right hemicolectomy (3 cases) simple detorsion (2 cases), Mickulics exteriorization-resection (1 case) and cecostomy (1 case). The operative mortality rate was 18.7%. There were no recurrences after cecopexy. The most frequent post-operative complications were bronchopneumonia (18.7%), and wound infection (18.7%).(ABSTRACT TRUNCATED AT 250 WORDS)

Comparison between measured and fick-derived values of hemodynamic and oxymetric variables in patients with acute myocardial infarction.

PURPOSE: Previous studies have compared the relationship between directly measured values for cardiac output, systemic oxygen consumption (VO2), and arteriovenous oxygen difference (D(A-v)O2) with those calculated by the Fick principle. However, the validity of Fick's principle in critically ill patients undergoing physiologic changes and pharmacologic interventions is unknown. The purpose of our study was to compare directly measured values for hemodynamic and oxymetric variables with those calculated by the Fick equation in patients with acute myocardial infarction, at baseline and after the hemodynamic changes produced by pharmacologic interventions. PATIENTS AND METHODS: Cardiac output, (VO2), and (D(A-v)O2) were measured in 33 patients with acute myocardial infarction, at baseline (50 +/- 30 hours after the onset of symptoms) and after pharmacologic intervention to relieve pulmonary congestion. These values were then compared with indirect values derived from the Fick equation. RESULTS: High and significant correlations were found between thermodilution and Fick-derived cardiac output at baseline (r = 0.91, p less than 0.001) and post-intervention (r = 0.92, p less than 0.001). Similarly, VO2 values measured by expired gas analysis showed a significant correlation with VO2 calculated by the Fick principle, at baseline (r = 0.85, p less than 0.001) and post-intervention (r = 0.84, p less than 0.001). Lastly, when D(A-v)O2 of arterial and mixed venous samples was measured by spectrophotometry and compared with calculated values, there was a significant correlation at baseline (r = 0.85, p less than 0.001) and after intervention (r = 0.85, p less than 0.001). Analysis of variance revealed no difference between measured and calculated values for the three variables under those two conditions. CONCLUSION: In patients with acute myocardial infarction, cardiac output, VO2, and D(A-v)O2 indirectly calculated by the Fick principle are equivalent to directly measured values, despite the various degrees of hemodynamic dysfunction and the currently used therapeutic interventions.